“Proforma ‘AA’

(See rules 9, 12, Forms FC-3A, FC-3B and FC-3C)

[To be executed by each office bearer and key functionary and member individually on non-judicial
stamp paper of Rs.10/- and attested by a Notary Public or 1st Class Magistrate]

AFFIDAVIT

I, Ubachak Mohanty (name of the Chief Functionary / Chairperson/ President/Secretary/ Chief

Executive Officer/ Managing Director/office bearer/key functionary/member), son/daughter/wife of
………………………………., resident of ………………………., having Aadhaar Number /PAN Card Number /
Passport Number / Voter Identity Card Number/ Driving Licence Number ……………… as the identity
proof, do hereby solemnly affirm on oath that I am the Chief Functionary / Chairperson/
President/Secretary/ Chief Executive Officer/ Managing Director/office bearer/ key functionary/
member (whichever is applicable) of ………………………………………………... (name of the applicant
organisation), having its registered office at ………………………………………. , and I have read and understood
the provisions of the Foreign Contribution (Regulation) Act, 2010 (42 of 2010) and confirm that all the
conditions as stipulated in sub-section (4) of section 12 of the said Act are fulfilled.

2. I also undertake to report to the Secretary to the Government of India, Ministry of Home
Affairs, Foreigners Division (Foreign Contribution Regulation Act Wing) about any violation of the
provisions of subsection (4) of section 12 of the Foreign Contribution (Regulation) Act, 2010 by the
applicant organisation or any of its members or office bearers or key functionaries that comes to my
knowledge.

3. I also understand that submission of any false or misleading information shall be punishable
under the applicable law.

Place:

Date:

Deponent

VERIFICATION

I, ……………………………., above named deponent do hereby verify that the contents of the aforesaid
paragraphs 1 to 3 are true to the best of my knowledge and nothing has been concealed therefrom.
Verified at ………………………….. on this the ………day of ……………………………

Place:

Date:

Deponent”.